1. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I GENNARO SARDELLA, MD, FACC,FESC O.U. of Invasive Cardiology, Dept. of Cardiovascular Sciences Policlinico Umberto I “Sapienza “ University of ROME Impact of Thrombectomy with EXPort catheter in Infarct Related Artery during Primary PCI on Procedural Outcome in patients with AMI (EXPIRA Trial). 24 Months Clinical Outcome Gennaro Sardella, Massimo Mancone, Emanuele Canali, Rocco Stio, Luigi Lucisano, Angelo Di Roma, Giulia Benedetti, Luciano Agati, Francesco Fedele

2. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I No relationship to disclose GENNARO SARDELLA MD FINANCIAL DISCLOSURE: Impact of Thrombectomy with EXPort catheter in Infarct Related Artery during Primary PCI on Procedural Outcome in patients with AMI (EXPIRA Trial). 24 Months Clinical Outcome

3. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I  In STEMI the “ no-flow” phenomenon is caused by the distal embolization after the IRA reopening. OOPS!! Distal embolization during Primary PCI No DE n = 167 (86.1%) DE n = 27 (13.9%) P Value Patency151 (92)19 (73)0.009 LVEF (%)51 ± 942 ± 140.005 LDH (Q72) 847 ± 6311612 ± 10080.001 Mortality15 (9)12 (44)< 0.001 Death/re- MI 23.921.50.48 (Henriques JPS et al Eur H J 2002:23-1112-17) No DE DE

4. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I Myocardial Perfusion After Primary PCI is the Strongest Predictor of Mortality independently from IRA reopening 80 85 90 95 3 2 0/1 100 Cumulative Survival (%) 024681012 75 Final Blush Score (patients with final TIMI 3 flow) Blush 1-Year Mortality 3 2 0/1 6.8% 13.2% 18.3% P=0.004 Stone GW, et al. J Am Coll Cardiol. 2002;39:591-597. Background “ Open Artery...but Closed Myocardium “!! PPCI Hardest Goal

5. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I Role of Adjunctive Mechanical Device in STEMI A comprehensive meta-analysis 11 Randomized Clinical Trial N= 2686 pts MANUAL ASPIRATION TRIALS 300 days600 days900 days1200 days 80% 85% 90% 95% 100% CUMULATIVE SURVIVAL Estimated number of pts to treat to save 1 life: 34 P= 0.011 (Burzotta F.,De Vita M.,LeFevre T,Dudek D.,Sardella G. et al EHJ Sept.2, 2009 ) Thrombectomy Standard PCI

6. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I Design  Prospective, randomized, double-arm, mono-centric study.  Primary end-point :  Final MBG ≥ 2 ;  90’ ST resolution (> 70% decrease of ST segment after PCI) Secondary end-point :  MACE 9 -24 months clinical f-u  Principal investigator G.Sardella MD  Prospective, randomized, double-arm, mono-centric study.  Primary end-point :  Final MBG ≥ 2 ;  90’ ST resolution (> 70% decrease of ST segment after PCI) Secondary end-point :  MACE 9 -24 months clinical f-u  Principal investigator G.Sardella MD Impact of Thrombectomy with EXPort catheter in Infarct Related Artery on procedural and clinical outcome in patients with AMI ( EXPIRA Trial ). 256 pts. (STEMI, at 6.8 ± 2.3 h from symptoms onset) 256 pts. (STEMI, at 6.8 ± 2.3 h from symptoms onset) (Heparin 7.500 U/I, GPIIb/IIIa, Aspirin, Clopidogrel 300 mg) 81 pts.excluded:  Cardiogenic shock  3-vessel / Left Main  TIMI >0-1  TS < 3  Contra to GPIIb/IIIa 81 pts.excluded:  Cardiogenic shock  3-vessel / Left Main  TIMI >0-1  TS < 3  Contra to GPIIb/IIIa 175 pts. eligible for 1:1 randomization 9-24 months clinical f-u Final MBG ≥ 2 ; 90’ ST resolution 88 pts randomized to Thrombectomy + PCI 88 pts randomized to Thrombectomy + PCI 87 pts randomized to Standard PCI 87 pts randomized to Standard PCI (G.Sardella et al J. Am. Coll. Cardiol 2009;53;309-315 )

7. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I Inclusion CriteriaExclusion Criteria  Age >18 yrs  STEMI within 6-9 hrs from symptoms onset  “De novo” coronary artery lesions  Native IRA ≥2.5 mm diameter  Angiographically identifiable occlusive thrombus (TS grade ≥ 3)  TIMI 0-1 at time of initial angiography  Previous AMI or CABG  Cardiogenic shock  3-vessel / Left Main CAD  Severe valvular heart disease  Unsuccessful PCI (no antegrade flow or 50% residual stenosis in the IRA)  Rescue / Facilitaded PCI  Contraindication to GP IIb/IIIa inhibitors Methods (G.Sardella et al J. Am. Coll. Cardiol 2009;53;309-315 ) Randomization after Angiography

8. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I Impact of Thrombectomy with EXPort catheter in Infarct Related Artery during Primary PCI on Procedural Outcome in patients with AMI (EXPIRA Trial). Total (n = 175)S-PCI (n = 87)EM-PCI (n = 88)p Value Age, yrs65.3 ± 11.264.6 ± 12.566.7 ± 14.10.298 Males (%)105 (60.0)48 (55.1)57 (64.7)0.218 Risk factors Hypertension (%)102 (58.3)43 (49.4)59 (67.0)0.021 Diabetes (%)37 (21.1)16 (18.4)21 (23.8)0.459 Smoking (%)66 (37.7)23 (26.4)43 (48.8)0.003 Obesity (%)7 (4.0)2 (2.3)5 (5.7)0.443 Family history of CAD (%)58 (33.1)32 (36.8)26 (29.5)0.338 Cholesterol, mg/dl ± SD163 ± 27167 ± 15161 ± 110.002 Triglycerides, mg/dl ± SD122 ± 37125 ± 26124 ± 310.817 Renal failure (%)14 (8.0)7 (8.0)7 (7.9)1.00 Killip class III (%)42 (24.0)25 (28.7)17 (19.3)0.160 Symptoms to balloon, h ± SD6.1 ± 1.36.1 ± 1.86.2 ± 0.90.642 LVEF, % ± SD41 ± 1340.7 ± 9.342 ± 10.50.192 ST-segment elevation, mV22.9 ± 13.522.3 ± 9.323.6 ± 10.50.384 Baseline clinical characteristics (G.Sardella et al J. Am. Coll. Cardiol 2009;53;309-315 )

9. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I Impact of Thrombectomy with EXPort catheter in Infarct Related Artery during Primary PCI on Procedural Outcome in patients with AMI (EXPIRA Trial). 24 Months Clinical Outcome Total (n = 175) S-PCI (n = 87) EM-PCI (n = 88) p Value Left anterior descending artery 76 (43.4)38 (43.7)38 (43.2)1.00 Left circumflex artery42 (24.0)20 (23.0)22 (25.0)0.859 Right coronary artery57 (32.6)29 (33.3)28 (31.8)0.872 BARI score, %28.9 ± 10.328.1 ± 9.229.7 ± 6.10.17 Multivessel disease (%)37 (26.8)16 (18.4)21 (23.8)0.459 Bifurcation (%)23 (13.1)11 (12.7)12 (13.6)1.00 Pre-thrombectomy thrombus score (%) 318 (10.3)9 (10.3)9 (10.6)1.00 462 (35.4)32 (36.8)30 (34.1)0.753 595 (54.3)47 (54.0)48 (54.5)1.00 “Direct” stenting69 (39.4)2 (2.3)67 (76.2)0.0001 Drug-eluting stent102 (58.3)53 (60.9)49 (55.7)0.540 Baseline procedural and angiographic characteristics (G.Sardella et al J. Am. Coll. Cardiol 2009;53;309-315 )

10. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I Impact of Thrombectomy with EXPort catheter in Infarct Related Artery on procedural and clinical outcome in patients with AMI ( EXPIRA Trial ). Primary End-points (G.Sardella et al J. Am. Coll. Cardiol 2009;53;309-315 ) TG CG TG CG

11. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I Impact of Thrombectomy with EXPort catheter in Infarct Related Artery on procedural and clinical outcome in patients with AMI ( EXPIRA Trial ). MRI Substudy (G.Sardella et al J. Am. Coll. Cardiol 2009;53;309-315 ) 75 patients w. Anterior AMI

12. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I Impact of Thrombectomy with EXPort catheter in Infarct Related Artery during Primary PCI on Procedural Outcome in patients with AMI (EXPIRA Trial). 24 Months Clinical Outcome Total (n = 169)S-PCI (n = 81)EM-PCI (n = 88) p Value Pharmacological therapy (%) Aspirin152 (86.8 )67 (82.7)76 (86.4)0.53 Clopidogrel10 (5.9)4 (4.9)5 (5.7)1.00 Coumarin derivatives5 (2.9) 2 (2.4)3 (3.4)1.00 Statins 155 (91.7)74 (91.3 )81 (92)1.00 Β-blocker148 (87.6)69 ( 85.2)79 (89.7)0.44 Calcium channels blockers30 (17.7)13 (16)17 (19.3)0.68 Nitrates 15 (8.9)6 (7.4)9 (10.2)0.59 Angiotensin-converting-enzyme inhibitor 100 (59.2)47 (58)53 (60.2)0.87 Angiotensin-II receptor antagonists 35 (20.7)15 (18.5)20 (22.7)0.57 Diuretics40 (23.7)19 (23.4)21 (23.8)1.00 Medication administration at 2-years follow-up

13. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I Impact of Thrombectomy with EXPort catheter in Infarct Related Artery during Primary PCI on Procedural Outcome in patients with AMI (EXPIRA Trial). 24 Months Clinical Outcome Variables Conventional PCI (n=87) Thrombus Aspiration (n=88) HR (95% CI) p v alues Cardiac death 6 (6.8%) * 0 (0%) 6.657 (1.642 – 8.457) 0.0001 Reinfarction1 (1.1%)0 (0%) - 0.999 TVR5 (5.7%)4 (4.5%) 1.302 (0.351 – 4.848) 0.651 MACE12 (13.6%)4 (4.5%) 3.105 (1.002 – 9.629) 0.050 Definite VLST0 (0%) - - Adverse clinical events at 2 years follow up. * 3pts died for VF 1 pt. died for Re-AMI 2 pts.died for HF

14. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I Impact of Thrombectomy with EXPort catheter in Infarct Related Artery during Primary PCI on Procedural Outcome in patients with AMI (EXPIRA Trial). 24 Months Clinical Outcome 2-years Survival-free from Cardiac Death 0 510 15 20 25 0,0 0,2 0,4 0,6 0,8 1,0 Months of Follow-up Survival Manual Thrombectomy Control Log rank= 0.012 Death reduced by 88% at 2 years

15. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I Impact of Thrombectomy with EXPort catheter in Infarct Related Artery during Primary PCI on Procedural Outcome in patients with AMI (EXPIRA Trial). 24 Months Clinical Outcome 2-years Cumulative Event-Free Survival Months of Follow-up 0 510 15 20 25 0,0 0,2 0,4 0,6 0,8 1,0 Cum Survival Manual Thrombectomy Control Log rank= 0.038

16. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I Impact of Thrombectomy with EXPort catheter in Infarct Related Artery during Primary PCI on Procedural Outcome in patients with AMI (EXPIRA Trial). 24 Months Clinical Outcome Variables Univariate analysis HR (95% CI) p values Multivariate analysis HR (95% CI) p values Randomization to Thrombus Aspiration 0.015 (0.004 – 0.370)0.0210.12 (0.006 – 0.251)0.006 Age1.004 (0.928 – 1.086)0.2151.508 (1.055 – 2.156)0.024 Diabetes6.970 (1.276 – 15.061)0.025 Hypertension3.634 (0.425 – 11.109)0.239 Symptoms to Balloon Time 1.145 (1.041 – 1.258)0.0051.322 (1.078 – 1.622)0.007 Final MBG < 28.833 (0.998 – 18.658)0.193 Univariate and multivariate analysis for cardiac death

17. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I Cardiac death (%) 0 1.8 11.1 38 0.001 MACE (%) 4.3 9.1 22.2 37.5 0.003 Impact of Thrombectomy with EXPort catheter in Infarct Related Artery during Primary PCI on Procedural Outcome in patients with AMI (EXPIRA Trial). 24 Months Clinical Outcome Relation between Final Myocardial Blush Grade and Cardiac Death and MACE at 2-years follow-up.

18. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I Cardiac death (%) 0.9 7.3 0.023 MACE (%) 3.7 17.6 0.002 Impact of Thrombectomy with EXPort catheter in Infarct Related Artery during Primary PCI on Procedural Outcome in patients with AMI (EXPIRA Trial). 24 Months Clinical Outcome Relation between % ST-segment resolution and Cardiac Death and MACE at 2-years follow-up.

19. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I  In our experience Thrombectomy during Primary PCI has been demonstrated to be safe and effective improving myocardial perfusion and reducing infarct size.  In this study a very long term follow-up (>1 year) was assessed in the setting of primary PCI treated with adjunctive manual thrombectomy.  A pretreatment with manual thrombectomy results in a lower cardiac mortality and a lower incidence of other MACEs at 2-year follow-up than conventional therapy alone.  We observed that the occurrence of cardiac death and MACE is significantly related to final MBG and ST-segment resolution.  The major limitations of our study are the limited number of patients and that was not powered to investigate the magnitude of the effect of thrombus aspiration on hard MACE that requests more powered RCT’s. Conclusion

20. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I Thank You !

21. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I  In our experience Thrombectomy has been demonstrated to be safe and effective in AMI setting during Primary PCI.  Compared with conventional stenting, in patients with intracoronary visible and occlusive thrombus, pretreatment with manual aspiration thrombectomy during primary PCI improves acutely the parameters of myocardial tissue perfusion and ST resolution in a well selected population.  The difference observed in term of Systolic Strain between the two groups suggest a rapid and better segmental function recovery in pts treated with Thrombectomy.  These data also confirm that Systolic Strain after primary PCI could be useful to evaluate if primary percutaneus reperfusion has been effective in terms of function recovery. Conclusion

22. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I Conclusion and Limits of the Study  For the first time a very long term follow-up (>1 year) was assessed in the setting of primary PCI treated with adjunctive manual thrombectomy.  The main finding of the present study is that a pre-treatment with manual thrombectomy during primary PCI results in a lower cardiac mortality and a lower incidence of other MACEs at 2-year follow-up than conventional therapy alone.  Our findings are in agreement with the results of the recently published single-centre TAPAS trial and the ATTEMPT study, the benefit of improved myocardial reperfusion seen in the EM-PCI resulted in a significant improvement of long term clinical outcome.  We observed that the occurrence of cardiac death and of MACE is significantly related to final MBG and ST-segment resolution as previously reported.  Our Study represents a single-center experience with a limited number of patients.  EXPIRA was designed to detect differences in myocardial reperfusion and it was not powered to investigate the magnitude of the effect of thrombus aspiration on clinical outcome. Nevertheless Kaplan Meier analysis showed a reduced mortality in patients randomized to manual thormbectomy with a mortality reduction of 88% (HR 0.12) at multivariate analysis.

23. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I Thank You !

24. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I 2.7 2.8 4.4 5.3 3.1 3.4 p = 0.0018 p = 0.05 p = 0.69 30-day mortality (%) Mechanical Thrombectomy Manual Aspiration Embolic Protection Role of Adjunctive Mechanical Device in STEMI A comprehensive meta-analysis 9 Randomized Clinical Trial N= 2417 pts

25. G.SARDELLA Dip.di SCIENZE CARDIOVASCOLARI POLICLINICO UMBERTO I (G.Sardella et al J. Am. Coll. Cardiol 2009;53;309-315 ) Impact of Thrombectomy with EXPort catheter in Infarct Related Artery on procedural and clinical outcome in patients with AMI ( EXPIRA Trial ). 9-month Clinical Follow-up